Ultrasonographic assessment of rectus abdominis muscle adaptation after deep inferior epigastric artery perforator (DIEP) flap surgery: Single institution retrospective study.

The impact of deep inferior epigastric artery perforator (DIEP) flap on abdominal wall integrity has been the topic of an ongoing debate with previous studies having reported conflicting results using various imaging modalities. Ultrasonography is a noninvasive, cost-effective, and readily available method for evaluating the changes to the rectus muscle after DIEP flap surgery. In the present study, we aimed to compare rectus abdominis muscle thickness between the operated and non-operated sides using ultrasound imaging. The muscle thickness was measured at the cross point of the midclavicular line and the level of the umbilicus and anterior superior iliac spine using real-time B-mode ultrasonography. The muscle anteroposterior diameters of the pedicle-dissected side and the control side were compared using paired t test. In total 31 patients with a mean follow-up of 70.18 weeks were included. The mean diameters at the level of the umbilicus of the operated and non-operated sides were 8.16 ±â€…1.83 and 8.14 ±â€…1.43 mm, respectively (P = .94). The mean thicknesses at the anterior superior iliac spine level were 7.74 ±â€…1.85 on the flap harvested side and 8.04 ±â€…1.84 mm on the control side (P = .35). There was no statistically significant difference between the 2 groups. Ultrasonography can be a reliable, inexpensive, and easily usable modality for evaluating donor site complication following DIEP flap. DIEP flap seems to have minimal impact on the abdominal donor site, and it may be safe and versatile to reconstruct the breast after mastectomy.

Assessment of Rectus Abdominis muscle thickness during isometric trunk and leg lifting exercises using extended field of view (EFOV) ultrasound.

AIM: The purpose of the present study was to establish which type of exercise is optimal for Rectus Abdominis (RA) muscle, by measuring thickness and length changes using the extended field of view ultrasonography (EFOV US) during different conditions. The second purpose was to estimate the reliability of EFOV US as a muscle morphology assessment tool. MATERIAL AND METHODS: Segmental muscle thickness and length of 11 young healthy adults was assessed during 1) rest and isometric 2) trunk lifting, 3) leg lifting and 4) combined trunk and leg lifting exercises with the use of EFOV US. RESULTS: RA muscle thickness was significantly greater during exercises compared to rest (p<0.05). It was also observed that proximal and proximal-middle segments showed significantly less thickness and length compared to distal-middle and distal segments (p<0.05). Even though no differences in thickness were observed between the exercises, leg lifting and combined trunk and leg lifting exercises affected more the distal segment of RA muscle (p<0.05). Moreover, no significant differences in length between exercises was found (p>0.05). Further, EFOV US displayed excellent reliability as the ICC values ranged from 0.82 to 0.97. CONCLUSIONS: According to our observations it seems that exercises that induce lifting of the legs might be more effective for the distal parts of RA muscle. EFOV appears to be a reliable diagnostic tool for measuring RA muscle thickness during rest and contracting states.

Establishing measurement properties in the assessment of inter-recti distance of the abdominal muscles in a postnatal women.

BACKGROUND: Diastasis of the rectus abdominis muscle is often evaluated in clinical practice but it is unknown which clinical method has the best measurement properties. OBJECTIVE: The aim of this study was to determine: (i) the criterion validity of the callipers, tape measure and finger-width to evaluate the inter-recti distance of the abdominal muscles compared to ultrasound; and (ii) inter-rater and retest reliability of these methods. DESIGN: Measurement study. METHODS: Two physiotherapists assessed the inter-recti distance of rectus abdominis on 50 women postnatally using the three clinical methods. These measurements were compared to ultrasound and assessed for inter-rater and retest reliability. RESULTS: Callipers had very good positive correlations with ultrasound (r = 0.85 to 0.99) and narrow limits of agreement (LOA) (<6 mm). Finger-width and tape measure had moderate to very good correlation with ultrasound (tape measure r = 0.82 to 0.98; finger-width r = 0.75 to 0.98) with wider limits of agreement (tape measure LOA <8 mm; finger-width LOA <18 mm). Callipers demonstrated excellent inter-rater (ICC = 0.80 to 0.99) and retest (ICC = 1.00) reliability. Inter-rater reliability testing was very good for tape measure (ICC = 0.80 to 0.97) and moderate to very good (ICC = 0.44 to 0.85) for finger-width. Retest reliability demonstrated very good reliability (ICC = 0.99 to 1.00) for both finger-width and tape measure. The largest inter-recti distances, strongest correlations and reliability were found at the level of the lower umbilicus. CONCLUSION: Callipers, tape measure and finger-width are valid and reliable methods of measuring inter-recti distance in postnatal women. Validity, and relative and absolute reliability were found to be the strongest using the callipers.

Spontaneous Retroperitoneal and Rectus Sheath Hemorrhage-Management, Risk Factors and Outcomes.

BACKGROUND: Spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH) is associated with high mortality in the literature, but studies on the subject are lacking. The objective of this study was to identify early predictors of the need for angiographic or surgical intervention (ASI) in patients with SRRSH and define risk factors for mortality. METHODS: We conducted a retrospective cohort study at a tertiary academic hospital. All patients with computed tomography-identified SRRSH between 2012 to 2017 were included. Exclusion criteria were age below 18 years, possible mechanical cause of SRRSH, aortic aneurysm rupture or dissection, and traumatic or iatrogenic sources of SRRSH. The primary outcome was the incidence of ASI and/or mortality. RESULTS: Of 100 patients included (median age 70 years, 52% males), 33% were transferred from another hospital, 82% patients were on therapeutic anticoagulation, and 90% had serious comorbidities. Overall mortality was 22%, but SRRSH-related mortality was only 6%. Sixteen patients underwent angiographic intervention (n = 10), surgical intervention (n = 5), or both (n = 1). Flank pain (OR 4.15, 95% CI 1.21-14.16, p = 0.023) and intravenous contrast extravasation (OR 3.89, 95% CI 1.23-12.27, p = 0.020) were independent predictors of ASI. Transfer from another hospital (OR 3.72, 95% CI 1.30-10.70, p = 0.015), age above 70 years (OR 4.24, 95% CI 1.25-14.32, p = 0.020), and systolic blood pressure below 110 mmHg at the time of diagnosis (OR 4.59, 95% CI 1.19-17.68, p = 0.027) were independent predictors of mortality. CONCLUSIONS: SRRSH is associated with high mortality but is typically not the direct cause. Most SRRSHs are self-limited and require no intervention. Pattern identification of ASI is hard.

Preoperative and Postoperative Assessment of Rectus Abdominis Muscle Size and Function following DIEP Flap Surgery.

BACKGROUND: Prospective evaluation of rectus abdominis muscle function after deep inferior epigastric artery perforator (DIEP) flap breast reconstruction is limited. Elimination of muscle harvest with this procedure is theoretically associated with preservation of rectus abdominis function and minimization of abdominal wall morbidity. In this study, the authors evaluate the change in rectus abdominis muscle size and function after DIEP flap surgery. METHODS: Patients undergoing unilateral DIEP flap surgery were recruited prospectively. Using computed tomography, the change in preoperative to postoperative rectus abdominis muscle size was compared between the operative side rectus abdominis muscle and the contralateral, nonoperative control rectus abdominis. Postoperative muscle integrity and contractility were evaluated using ultrasound by comparing the change in rectus abdominis muscle dimensions between contractile and relaxed states. The BREAST-Q was used to score patients' subjective satisfaction. Clinical and radiographic hernia rates were also calculated. RESULTS: Analysis of 26 paired rectus abdominis muscles revealed no significant change in muscle size from preoperative to postoperative values. Furthermore, dimensional change from contractile to relaxed states postoperatively was similar for paired operative and nonoperative rectus abdominis muscles. BREAST-Q scores indicated a high degree of satisfaction in abdominal well-being, breast satisfaction, and surgical experience domains. There were no clinical or radiographic abdominal wall hernias noted. CONCLUSIONS: The DIEP flap is an effective surgical procedure with minimal abdominal wall morbidity that is associated with no measurable loss in rectus abdominis size and contractile function postoperatively. Patients are highly satisfied with their abdominal function postoperatively using this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Ultrasound Assessment of Abdominal Muscle Thickness in Postpartum vs Nulliparous Women.

OBJECTIVE: The purpose of this study was to determine the effect size in measurable change of abdominal musculature morphology using ultrasonography in postpartum women within 1 month of a healthy, vaginal delivery. METHODS: One hundred fifty-six participants were recruited for this study. B-mode ultrasound imaging was used to measure abdominal muscle thickness on 80 nulliparous women and 76 mothers who had delivered within the past 4 weeks. Measures were taken for the upper and lower rectus abdominus, external and internal obliques, and transversus abdominus at rest. RESULTS: Statistically significant differences were found in the thickness of the rectus abdominus muscle at both sites; upper (P < .0001) and lower (P < .0001) as well as the internal oblique (P < .0001). All 3 muscles were thinner in postpartum participants (8.29 ± 1.83 mm, 8.89 ± 2.29 mm, and 7.06 ± 1.82 mm, respectively) within the first month of delivery than in controls (10.82 ± 1.93 mm, 11.13 ± 2.38 mm, and 8.36 ± 1.87 mm, respectively). Large effect sizes were found for the influence of pregnancy on the rectus muscle segments (1.35 for the upper rectus abdominus and 1.00 for the lower rectus abdominus) and a medium effect size for the internal oblique (0.71). No significant differences were observed in the remaining 2 muscles. CONCLUSION: This study showed that there are differences in morphology of the abdominal muscles in pregnant women vs nonpregnant controls. The large effect sizes reported may provide the basis for future studies examining relationships between morphology, functional change, and back pain during pregnancy.

Analysis of the abdominal musculo-aponeurotic anatomy in rectus diastasis: comparison of CT scanning and preoperative clinical assessment with direct measurement intraoperatively.

PURPOSE: To evaluate and compare the consistency of agreement of two methods for measuring abdominal rectus diastasis (ARD), preoperative computed tomography (CT) scanning and preoperative clinical assessment were compared with direct measurement intraoperatively. METHODS: Fifty-five consecutive patients were retrieved from an ongoing prospective randomised trial comparing two operative techniques for the repair of ARD. All patients underwent a preoperative clinical assessment and CT scan, and the results were compared with intraoperative measurement of the ARD width. Agreement between methods was described with Bland-Altman plots (BA plots) and calculated using Lin's Concordance Correlation Coefficient (CCC). RESULTS: The median width of the diastasis was 4.0 cm in the upper midline and 3.0 cm in the lower midline for the intraoperative measurement. BA plots showed that measurements on CT and intraoperatively are not in agreement in the lower midline, whereas the agreement was stronger between the clinical and the intraoperative method. The CCC was higher for clinical vs. intraoperative measurement (0.479) than for CT vs. intraoperative measurement (-0.002) in the lower midline, although the agreement was over all low. CT scanning underestimated the width of the ARD when compared to 87 % of preoperative clinical assessments, and 83 % of intraoperative measurements. Preoperative clinical assessment overestimated ARD in 35 % when compared with intraoperative measurements. CONCLUSION: Clinical assessment prior to surgery provides more accurate information than CT scanning in the assessment of ARD width. CT scanning underestimates ARD width when compared with intraoperative measurement.

Ultrasound assessment of asymmetric hypertrophy of the rectus abdominis muscle and prevalence of associated injury in professional tennis players.

OBJECTIVE: To assess rectus abdominis (RA) thickness and injury prevalence using ultrasound in a group of professional tennis players. Observations with regard to muscle fiber repair is described. We likewise studied the potential link between RA volume asymmetry and the risk of muscle strain. MATERIALS AND METHODS: The degree of asymmetry between the different RA slices was assessed using ultrasound in 61 professional tennis players. The history of RA injury in these tennis players was likewise studied, taking into account the following factors: dominant vs non-dominant arm, history of RA strains, duration thereof and number of recurrences. Ultrasound examination was performed with an 8- to 12-MHz linear multi-frequency transducer. RESULTS: Ultrasound revealed the presence of fibrous scar tissue in the RA muscle in 18 cases (29.5%). In all instances, the lesion was located in the RA on the side of the nondominant arm. In 16 of the cases, the lesion was infra-umbilical and L2 was affected in two cases. The mean maximum width of the fibrous repair tissue was 9 mm (range 5-16). The mean distance between the umbilicus and the scar was 5.8 cm (range 2.9-11.4). Statistical study of the ultrasound measurements obtained for the different slices revealed statistically significant differences between the different depths and according to arm dominance. CONCLUSIONS: In the series studied, the prevalence of RA muscle lesion in professional tennis players was 29.5%. Asymmetric hypertrophy of the RA muscle appears to constitute a risk factor for suffering an injury in this location.

Rectus sheath plication in abdominoplasty: assessment of its longevity and a review of the literature.

BACKGROUND: Correction of rectus diastasis during abdominoplasty is controversial. Few published studies have investigated the long-term value of plication. This prospective study aims to assess the long-term durability of plication of the rectus sheath in abdominoplasty using ultrasound. METHODS: A total of 28 consecutive abdominoplasty patients underwent rectus plication by the senior author (FSF) since 2006, using a 0/0 looped nylon suture. Rectus diastasis was measured preoperatively and postoperatively at 3, 6 and 12 month's intervals using a standardised ultrasound (7.5 MHz) probe, by the single senior radiologist (GJD). Diastasis of the recti was assessed at three fixed points: at the umbilicus, 6 cm above and 6 cm below the umbilicus. Diastasis was categorised using the Beer classification. RESULTS: All patients were female with a mean age of 36 years and average of body mass index (BMI) 26 kg m(-2). The majority of subjects had previous abdominal surgery including caesarean sections (82%, n = 23) and had at least one previous pregnancy (87%), with only two patients (8.7%) in the study being nulliparous. Correction of diastasis was maintained in all patients despite previous pregnancies and abdominal surgery. Postoperative follow-up time averaged 28 months (range 12-43 months). According to the Beer classification, there was no recurrence of rectus diastasis at the 12-month postoperative ultrasound measurements. A significant reduction in the mean distance between rectus muscles before surgery and 12 months postoperatively was noted. Previous surgery did not have a statistically significant affect on preoperative rectus distance. CONCLUSIONS: Vertical rectus plication with a non-absorbable suture demonstrates long-term durable results without any suture-related complications. Patient factors such as extent of preoperative rectus diastases and previous abdominal surgery did not appear to have a significant effect on the durability of the corrected diastasis.

An assessment of between-recti distance and divarication in patients with and without abdominal aortic aneurysm.

INTRODUCTION: The study assessed whether there is a greater incidence of divarication of the recti and whether between-recti distance is greater in patients with abdominal aortic aneurysm (AAA). PATIENTS AND METHODS: The study consisted of two parts: a radiological and a clinical assessment. All patients with a confirmed AAA on computerised tomography were included and compared with patients in whom AAA was excluded with imaging. Between-recti distance was measured using a computerised image viewer and clinical divarication was assessed by a surgical registrar or consultant. RESULTS: In the radiological part of the study, 108 patients with AAA were compared with 84 with colorectal cancer. Median between-recti distance was 38 mm (range, 25-59 mm) in the AAA group and 27 mm (range, 20-44.5 mm) in the non-AAA group (P=0.006). AAA diameter did not correlate with between-recti distance. The clinical study included 50 patients (25 AAA). The groups were well matched, with only a greater incidence of diabetes in the AAA group (20% vs 0%; P=0.018). AAA patients were more likely to have clinically detected divarication of the recti (76% vs 36%; P=0.004). CONCLUSIONS: Patients with AAA have greater radiological and clinical evidence of divarication. It is suggested that patients with divarication be screened for AAA.

Preoperative color-Doppler assessment of vascularisation of the rectus abdominis: anatomic basis of breast reconstruction with a transverse rectus abdominis myocutaneous flap--a prospective study.

The unipedicled TRAM flap is an useful alternative to breast reconstruction after mastectomy in patients who refuse mammary implants. There is however the risk of unpredictable partial skin necrosis even after rigorous surgical procedures. Certain authors have proposed color flow doppler assessment before reconstructive surgery better to identify the vascular network and optimise patient selection. We performed a prospective study in 20 outpatients in order to compare preoperative assessment of the blood supply to the abdominal flap with the operative findings. An Ultramark 9 HDI (Advanced Technology Laboratories) equipped with a high frequency (10 Mhz) linear probe was used to measure blood flow and vessel caliber in the epigastric a. and perforating vessels (localisation, number; peak flow). Despite three limiting factors (anatomic, technical, morphologic) the results obtained in this series could be used to determine the indications for a TRAM flap.